NEW PATIENT REGISTRATION FORM



Gender Identity

Home Address
Postal Address

Contact Detail
Medicare Details

Drivers License

Pension or Health Care Card Details

Personal details

Stratford Medical Centre and Wheels of Wellness participate in Quality Improvement involving the sending of de-identification information for Health Data. Please inform reception if you do not wish to participate.

Privacy

Your medical record is a confidential document. It is always the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.

Please refer to our Privacy Policy located at Reception or via our website.




Yes

Do you wish to receive SMS notifications from Stratford Medical Centre?


Yes

Yes

Yes

Yes

Yes

If you request to communicate with us via email, we remind you that this is not encrypted, and we do not send information via this means, without your consent.

Digital Signature

Date